Things to Consider Before Choosing Your Health Care Agent(s) Your health care agent(s) will need to be trusted to make decisions for you that would likely be the health care decisions you would make for yourself, in the unfortunate event that something has happened to you and you can no longer comprehend your medical situation or treatment options. Have I discussed my choice for my agent(s) and my health care wishes with my other family members and loved ones? Will the person(s) I name as my agent(s) be comfortable with being my agent(s) and be willing to follow my wishes for my health care? Will the person(s) I name as my agent(s) be able to speak on my behalf and follow through with my wishes for my health care? Suggested Topics To Discuss With Your Health Care Agent(s) Think about and discuss an occasion when a friend or relative had a life changing medical event and talk with your agents and family about what you would want or not want for yourself based upon their experience. Consider what the minimum quality of life is that you would accept to be sustained by medical treatments or medical intervention. The topics listed below may or may not be important in your view of your quality of life. The following questions are intended to help you begin to clarify your wishes for your agent(s) in the event they are called upon to make medical decisions for you. Once you ve clarified your wishes, it is often helpful for you to put them in writing in your Health Care Power of Attorney (see Statement of Desires section on page 4 of the Wisconsin State Health Care Power of Attorney). Imagine a situation in which a stroke or other medical problem has permanently limited your abilities: 1) How aware of my environment would I need to be? Able to recognize who I am. Able to recognize and remember where I am. Able to recognize my family and loved ones. Etc. 2) How would I minimally need to be able to communicate? Able to communicate through talking. Able to communicate through writing. Able to communicate through shaking my head yes or no. Able to communicate through blinking my eyes or squeezing a hand. Etc. 3) How independent would I need to be? Able to live on my own. Able to live in assisted living or with periodic visits for support. Able to live with up to 12-24 hours of assistance in my home. Able to live in a nursing home setting. Etc. 4) How much physical pain would I be willing to live with? Able to live with minimal physical pain. Able to live with moderate physical pain, requiring some medication. Able to live with physical pain that requires medication that may interfere with my being awake or ability to think. Able to live with severe physical pain that requires high doses of medication that keeps me sedated or sleeping. kcs 05/21/2009
5) What medical treatments would I be willing to accept to maintain at least my minimum quality of life long term? (The benefits, side effects, and limitations of medical treatment options should be discussed with your physician.) Antibiotics Tube Feeding /Artificial nutrition (used if I am unable to eat food) IV Fluids/Artificial hydration (used if I am unable to drink fluids) Kidney dialysis (used if my kidneys stop working) Cardiopulmonary resuscitation, also called CPR (used if my heart stops beating) Respirator (a machine used to keep me breathing if I am unable to breathe on my own) Etc. 6) How certain do I want it to be that I would be able to recover at least this minimum quality of life before my agents say yes or no to medical treatment that would attempt to sustain or restore me? I would want medical treatments continued until there was a high degree of certainty that I would not regain my minimum quality of life. I would NOT want to medical treatments attempted that would more likely to result in my being sustained in a condition that is less than what I consider a minimum quality of life. I would want all attempts of medical treatments that might restore me or maintain my physical life, regardless of the quality of life concerns. Etc. Additional important discussion questions: How do I feel about medical treatment that prolongs my life but does not add to quality of life? What is my attitude toward death? How do I feel about the use of life-sustaining measures in the face of terminal illness or coma? How do I feel about the use of life-sustaining measures in the face of irreversible chronic illness (e.g., Alzheimer s disease, Lung or heart failure, etc.)? How do my religious beliefs affect my attitude toward serious or terminal illness? Do I want to donate parts of my body to someone else at the time of my death? (This is referring to organ donation.) What else do I feel is important for my agent(s) to know? Important Note Over time, your beliefs or attitudes in any area can change. You should review you Health Care Power of Attorney form every year and inform your health care agent(s) of the change in your wishes and of any serious or significant change in your medical condition. In the event you are informed of a terminal illness, the illness, as well as the ramifications of it, should be discussed with agent(s). How well your health care agent is able to follow through with your wishes largely depends on how well you have prepared them. kcs 05/21/2009
DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division of Public Health Chapter 155.30(1).(3) F-0085 (Rev. 8/08) Effective Date: April 1, 2008 608 266-1251 POWER OF ATTORNEY FOR HEALTH CARE DOCUMENT NOTICE TO PERSON MAKING THIS DOCUMENT YOU HAVE THE RIGHT TO MAKE DECISIONS ABOUT YOUR HEALTH CARE. NO HEALTH CARE MAY BE GIVEN TO YOU OVER YOUR OBJECTION, AND NECESSARY HEALTH CARE MAY NOT BE STOPPED OR WITHHELD IF YOU OBJECT. BECAUSE YOUR HEALTH CARE PROVIDERS IN SOME CASES MAY NOT HAVE HAD THE OPPORTUNITY TO ESTABLISH A LONG-TERM RELATIONSHIP WITH YOU, THEY ARE OFTEN UNFAMILIAR WITH YOUR BELIEFS AND VALUES AND THE DETAILS OF YOUR FAMILY RELATIONSHIPS. THIS POSES A PROBLEM IF YOU BECOME PHYSICALLY OR MENTALLY UNABLE TO MAKE DECISIONS ABOUT YOUR HEALTH CARE. IN ORDER TO AVOID THIS PROBLEM, YOU MAY SIGN THIS LEGAL DOCUMENT TO SPECIFY THE PERSON WHOM YOU WANT TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOU ARE UNABLE TO MAKE THOSE DECISIONS PERSONALLY. THAT PERSON IS KNOWN AS YOUR HEALTH CARE AGENT. YOU SHOULD TAKE SOME TIME TO DISCUSS YOUR THOUGHTS AND BELIEFS ABOUT MEDICAL TREATMENT WITH THE PERSON OR PERSONS WHOM YOU HAVE SPECIFIED. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF HEALTH CARE THAT YOU DO OR DO NOT DESIRE, AND YOU MAY LIMIT THE AUTHORITY OF YOUR HEALTH CARE AGENT. IF YOUR HEALTH CARE AGENT IS UNAWARE OF YOUR DESIRES WITH RESPECT TO A PARTICULAR HEALTH CARE DECISION, HE OR SHE IS REQUIRED TO DETERMINE WHAT WOULD BE IN YOUR BEST INTERESTS IN MAKING THE DECISION. THIS IS AN IMPORTANT LEGAL DOCUMENT. IT GIVES YOUR AGENT BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU. IT REVOKES ANY PRIOR POWER OF ATTORNEY FOR HEALTH CARE THAT YOU MAY HAVE MADE. IF YOU WISH TO CHANGE YOUR POWER OF ATTORNEY FOR HEALTH CARE, YOU MAY REVOKE THIS DOCUMENT AT ANY TIME BY DESTROYING IT, BY DIRECTING ANOTHER PERSON TO DESTROY IT IN YOUR PRESENCE, BY SIGNING A WRITTEN AND DATED STATEMENT OR BY STATING THAT IT IS REVOKED IN THE PRESENCE OF TWO WITNESSES. IF YOU REVOKE, YOU SHOULD NOTIFY YOUR AGENT, YOUR HEALTH CARE PROVIDERS AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY. IF YOUR AGENT IS YOUR SPOUSE AND YOUR MARRIAGE IS ANNULLED OR YOU ARE DIVORCED AFTER SIGNING THIS DOCUMENT, THE DOCUMENT IS INVALID. EXAMPLE YOU MAY ALSO USE THIS DOCUMENT TO MAKE OR REFUSE TO MAKE AN ANATOMICAL GIFT UPON YOUR DEATH. IF YOU USE THIS DOCUMENT TO MAKE OR REFUSE TO MAKE AN ANATOMICAL GIFT, THIS DOCUMENT REVOKES ANY PRIOR DOCUMENT OF GIFT THAT YOU MAY HAVE MADE. YOU MAY REVOKE OR CHANGE ANY ANATOMICAL GIFT THAT YOU MAKE BY THIS DOCUMENT BY CROSSING OUT THE ANATOMICAL GIFTS PROVISION IN THIS DOCUMENT. DO NOT SIGN THIS DOCUMENT UNLESS YOU CLEARLY UNDERSTAND IT. IT IS SUGGESTED THAT YOU KEEP THE ORIGINAL OF THIS DOCUMENT ON FILE WITH YOUR PHYSICIAN. 1
POWER OF ATTORNEY FOR HEALTH CARE Document made this day of (month), (year). I, Your Name CREATION OF POWER OF ATTORNEY FOR HEALTH CARE Home Street Address, City, State, Zip Your Date of Birth (print-name, address and date of birth), being of sound mind, intend by this document to create a power of attorney for health care. My executing this power of attorney for health care is voluntary. Despite the creation of this power of attorney for health care, I expect to be fully informed about and allowed to participate in any health care decision for me, to the extent that I am able. For the purposes of this document, 'health care decision' means an informed decision to accept, maintain, discontinue or refuse any care, treatment, service or procedure to maintain, diagnose or treat my physical or mental condition. death. In addition, I may, by this document, specify my wishes with respect to making an anatomical gift upon my DESIGNATION OF HEALTH CARE AGENT If I am no longer able to make health care decisions for myself, due to my incapacity, I hereby designate Name of person (over the age of 18) who you want to make decisions for you, His/Her Home Street Address, City, State, Zip His/Her phone number(s) (print name, address and telephone number) to be my health care agent for the purpose of making health care decisions on my behalf. If he or she is ever unable or unwilling to do so, I hereby designate: Name of person (over the age of 18) who you want to serve as a backup decision maker, His/Her Home Street Address, City, State, Zip His/Her phone number(s) (print name, address and telephone number) to be my alternate health care agent for the purpose of making health care decisions on my behalf. Neither my health care agent nor my alternate health care agent whom I have designated is my health care provider, an employee of my health care provider, an employee of a health care facility in which I am a patient or a spouse of any of those persons, unless he or she is also my relative. For purposes of this document, 'incapacity' exists if 2 physicians or a physician and a psychologist who have personally examined me sign a statement that specifically expresses their opinion that I have a condition that means that I am unable to receive and evaluate information effectively or to communicate decisions to such an extent that I lack the capacity to manage my health care decisions. A copy of that statement must be attached to this document. EXAMPLE 2
GENERAL STATEMENT OF AUTHORITY GRANTED Unless I have specified otherwise in this document, if I ever have incapacity I instruct my health care provider to obtain the health care decision of my health care agent, if I need treatment, for all of my health care and treatment. I have discussed my desires thoroughly with my health care agent and believe that he or she understands my philosophy regarding the health care decisions I would make if I were able. I desire that my wishes be carried out through the authority given to my health care agent under this document. If I am unable, due to my incapacity, to make a health care decision, my health care agent is instructed to make the health care decision for me, but my health care agent should try to discuss with me any specific proposed health care if I am able to communicate in any manner, including by blinking my eyes. If this communication cannot be made, my health care agent shall base his or her decision on any health care choices that I have expressed prior to the time of the decision. If I have not expressed a health care choice about the health care in question and communication cannot be made, my health care agent shall base his or her health care decision on what he or she believes to be in my best interest. LIMITATIONS ON MENTAL HEALTH TREATMENT My health care agent may not admit or commit me on an inpatient basis to an institution for mental diseases, an intermediate care facility for the mentally retarded, a state treatment facility or a treatment facility. My health care agent may not consent to experimental mental health research or psychosurgery, electroconvulsive treatment or drastic mental health treatment procedures for me. ADMISSION TO NURSING HOMES OR COMMUNITY-BASED RESIDENTIAL FACILITIES My health care agent may admit me to a nursing home or community-based residential facility for short-term stays for recuperative care or respite care. If I have checked 'Yes' to the following, my health care agent may admit me for a purpose other than recuperative care or respite care, but if I have checked "No" to the following, my health care agent may not so admit me: (These three questions are about the authority you would be granting to the Agent [decision maker]) 1. A nursing home - - Yes No (If you indicate No and nursing home care is required, a guardian will usually have to be appointed by the court to admit you to the nursing home) 2. A community-based residential facility - - Yes No (If you indicate No and a community-based residential facility is required, a guardian will usually have to be appointed by the court to admit you to the community-based residential facility) EXAMPLE If I have not checked either 'Yes' or 'No' immediately above, my health care agent may admit me only for short-term stays for recuperative care or respite care. 3
PROVISION OF FEEDING TUBE If I have checked 'Yes' to the following, my health care agent may have a feeding tube withheld or withdrawn from me, unless my physician has advised that, in his or her professional judgment, this will cause me pain or will reduce my comfort. If I have checked 'No' to the following, my health care agent may not have a feeding tube withheld or withdrawn from me. My health care agent may not have orally ingested nutrition or hydration withheld or withdrawn from me unless provision of the nutrition or hydration is medically contraindicated. Withhold or withdraw a feeding tube - - Yes No If I have not checked either 'Yes' or 'No' immediately above, my health care agent may not have a feeding tube withdrawn from me. HEALTH CARE DECISIONS FOR PREGNANT WOMEN If I have checked 'Yes' to the following, my health care agent may make health care decisions for me even if my agent knows I am pregnant. If I have checked 'No' to the following, my health care agent may not make health care decisions for me if my health care agent knows I am pregnant. Health care decision if I am pregnant - - Yes No (or N/A for males) If I have not checked either 'Yes' or 'No' immediately above, my health care agent may not make health care decisions for me if my health care agent knows I am pregnant. STATEMENT OF DESIRES, SPECIAL PROVISIONS OR LIMITATIONS In exercising authority under this document, my health care agent shall act consistently with my following stated desires, if any, and is subject to any special provisions or limitations that I specify. The following are any specific desires, provisions or limitations that I wish to state (add more items if needed): 1. This is the space where you might wish to write instructions about how your agent(s) is to make decisions 2. regarding you health care treatment. Often, it is helpful if you include a statement about your values and 3. perspectives concerning what minimum quality of life you would want to have medically maintained. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH Subject to any limitations in this document, my health care agent has the authority to do all of the following: (a) Request, review and receive any information, oral or written, regarding my physical or mental health, including medical and hospital records. (b) Execute on my behalf any documents that may be required in order to obtain this information. (c) Consent to the disclosure of this information. EXAMPLE 4
(The principal and the witnesses all must sign the document at the same time.) SIGNATURE OF PRINCIPAL (Person creating the Power of Attorney for Health Care) Signature Do not sign or date this document until and the witnesses are present Date (The signing of this document by the principal revokes all previous powers of attorney for health care documents.) STATEMENT OF WITNESSES I know the principal personally and I believe him or her to be of sound mind and at least 18 years of age. I believe that his or her execution of this power of attorney for health care is voluntary. I am at least 18 years of age, am not related to the principal by blood, marriage or adoption and am not directly financially responsible for the principal's health care. I am not a health care provider who is serving the principal at this time, an employee of the health care provider, other than a chaplain or a social worker, or an employee, other than a chaplain or a social worker, of an inpatient health care facility in which the declarant is a patient. I am not the principal's health care agent. To the best of my knowledge, I am not entitled to and do not have a claim on the principal's estate. Witness Number 1 (Print) Name Independent Person (See Above Paragraph For Exclusions) Date Address Signature Witness Number 2 (Print) Name Independent Person (See Above Paragraph For Exclusions) Date Address Signature EXAMPLE STATEMENT OF HEALTH CARE AGENT AND ALTERNATE HEALTH CARE AGENT (OPTIONAL*) (*Signatures of the designated decision makers or agents are suggested but not required for the document to be completed.) I understand that Your Name (name of principal) has designated me to be his or her health care agent or alternate health care agent if he or she is ever found to have incapacity and unable to make health care decisions himself or herself. Your Name (name of principal) has discussed his or her desires regarding health care decisions with me. Agent's Signature Signature of Designated Decision Maker Address His/Her Home Street Address, City, State, Zip Alternate's Signature Signature of the Backup Decision Maker Address His/Her Home Street Address, City, State, Zip Failure to execute a power of attorney for health care document under chapter 155 of the Wisconsin Statutes creates no presumption about the intent of any individual with regard to his or her health care decisions. This power of attorney for health care is executed as provided in chapter 155 of the Wisconsin Statutes. 5
ANATOMICAL GIFTS (optional) Upon my death: I wish to donate only the following organs or parts: (specify the organs or parts). I wish to donate any needed organ or part. I wish to donate my body for anatomical study if needed. I refuse to-make an anatomical gift. (If this revokes a prior commitment that I have made to make an anatomical gift to a designated donee, I will attempt to notify the donee to which or to whom I agreed to donate.) EXAMPLE Failing to check any of the lines immediately above creates no presumption about my desire to make or refuse to make an anatomical gift. Signature Date Division of Health, P.O. Box 309, Madison, WI 53701 6
DEPARTMENT OF HEALTH SERVICES Division of Public Health F-00085 (Rev. 01/09) STATE OF WISCONSIN Chapter 155.30(1),(3) Effective Date: January 1, 2009 608 266-1251 POWER OF ATTORNEY FOR HEALTH CARE DOCUMENT NOTICE TO PERSON MAKING THIS DOCUMENT YOU HAVE THE RIGHT TO MAKE DECISIONS ABOUT YOUR HEALTH CARE. NO HEALTH CARE MAY BE GIVEN TO YOU OVER YOUR OBJECTION, AND NECESSARY HEALTH CARE MAY NOT BE STOPPED OR WITHHELD IF YOU OBJECT. BECAUSE YOUR HEALTH CARE PROVIDERS IN SOME CASES MAY NOT HAVE HAD THE OPPORTUNITY TO ESTABLISH A LONG TERM RELATIONSHIP WITH YOU, THEY ARE OFTEN UNFAMILIAR WITH YOUR BELIEFS AND VALUES AND THE DETAILS OF YOUR FAMILY RELATIONSHIPS. THIS POSES A PROBLEM IF YOU BECOME PHYSICALLY OR MENTALLY UNABLE TO MAKE DECISIONS ABOUT YOUR HEALTH CARE. IN ORDER TO AVOID THIS PROBLEM, YOU MAY SIGN THIS LEGAL DOCUMENT TO SPECIFY THE PERSON WHOM YOU WANT TO MAKE HEALTH CARE DECISIONS FOR YOU IF YOU ARE UNABLE TO MAKE THOSE DECISIONS PERSONALLY. THAT PERSON IS KNOWN AS YOUR HEALTH CARE AGENT. YOU SHOULD TAKE SOME TIME TO DISCUSS YOUR THOUGHTS AND BELIEFS ABOUT MEDICAL TREATMENT WITH THE PERSON OR PERSONS WHOM YOU HAVE SPECIFIED. YOU MAY STATE IN THIS DOCUMENT ANY TYPES OF HEALTH CARE THAT YOU DO OR DO NOT DESIRE, AND YOU MAY LIMIT THE AUTHORITY OF YOUR HEALTH CARE AGENT. IF YOUR HEALTH CARE AGENT IS UNAWARE OF YOUR DESIRES WITH RESPECT TO A PARTICULAR HEALTH CARE DECISION, HE OR SHE IS REQUIRED TO DETERMINE WHAT WOULD BE IN YOUR BEST INTERESTS IN MAKING THE DECISION. THIS IS AN IMPORTANT LEGAL DOCUMENT. IT GIVES YOUR AGENT BROAD POWERS TO MAKE HEALTH CARE DECISIONS FOR YOU. IT REVOKES ANY PRIOR POWER OF ATTORNEY FOR HEALTH CARE THAT YOU MAY HAVE MADE. IF YOU WISH TO CHANGE YOUR POWER OF ATTORNEY FOR HEALTH CARE, YOU MAY REVOKE THIS DOCUMENT AT ANY TIME BY DESTROYING IT, BY DIRECTING ANOTHER PERSON TO DESTROY IT IN YOUR PRESENCE, BY SIGNING A WRITTEN AND DATED STATEMENT OR BY STATING THAT IT IS REVOKED IN THE PRESENCE OF TWO WITNESSES. IF YOU REVOKE, YOU SHOULD NOTIFY YOUR AGENT, YOUR HEALTH CARE PROVIDERS AND ANY OTHER PERSON TO WHOM YOU HAVE GIVEN A COPY. IF YOUR AGENT IS YOUR SPOUSE AND YOUR MARRIAGE IS ANNULLED OR YOU ARE DIVORCED AFTER SIGNING THIS DOCUMENT, THE DOCUMENT IS INVALID. YOU MAY ALSO USE THIS DOCUMENT TO MAKE OR REFUSE TO MAKE AN ANATOMICAL GIFT UPON YOUR DEATH. IF YOU USE THIS DOCUMENT TO MAKE OR REFUSE TO MAKE AN ANATOMICAL GIFT, THIS DOCUMENT REVOKES ANY PRIOR RECORD OF GIFT THAT YOU MAY HAVE MADE. YOU MAY REVOKE OR CHANGE ANY ANATOMICAL GIFT THAT YOU MAKE BY THIS DOCUMENT BY CROSSING OUT THE ANATOMICAL GIFTS PROVISION IN THIS DOCUMENT. DO NOT SIGN THIS DOCUMENT UNLESS YOU CLEARLY UNDERSTAND IT. IT IS SUGGESTED THAT YOU KEEP THE ORIGINAL OF THIS DOCUMENT ON FILE WITH YOUR PHYSICIAN.
F-00085 (Rev. 01/09) Page 2 of 6 POWER OF ATTORNEY FOR HEALTH CARE Document made this day of (month), (year). CREATION OF POWER OF ATTORNEY FOR HEALTH CARE I, (print name, address and date of birth), being of sound mind, intend by this document to create a power of attorney for health care. My executing this power of attorney for health care is voluntary. Despite the creation of this power of attorney for health care, I expect to be fully informed about and allowed to participate in any health care decision for me, to the extent that I am able. For the purposes of this document, health care decision means an informed decision to accept, maintain, discontinue or refuse any care, treatment, service or procedure to maintain, diagnose or treat my physical or mental condition. In addition, I may, by this document, specify my wishes with respect to making an anatomical gift upon my death. DESIGNATION OF HEALTH CARE AGENT If I am no longer able to make health care decisions for myself, due to my incapacity, I hereby designate print name, address and telephone number) to be my health care agent for the purpose of making health care decisions on my behalf. If he or she is ever unable or unwilling to do so, I hereby designate (print name, address and telephone number) to be my alternate health care agent for the purpose of making health care decisions on my behalf. Neither my health care agent nor my alternate health care agent whom I have designated is my health care provider, an employee of my health care provider, an employee of a health care facility in which I am a patient or a spouse of any of those persons, unless he or she is also my relative. For purposes of this document, incapacity exists if 2 physicians or a physician and a psychologist who have personally examined me sign a statement that specifically expresses their opinion that I have a condition that means that I am unable to receive and evaluate information effectively or to
F-00085 (Rev. 01/09) Page 3 of 6 communicate decisions to such an extent that I lack the capacity to manage my health care decisions. A copy of that statement must be attached to this document. GENERAL STATEMENT OF AUTHORITY GRANTED Unless I have specified otherwise in this document, if I ever have incapacity I instruct my health care provider to obtain the health care decision of my health care agent, if I need treatment, for all of my health care and treatment. I have discussed my desires thoroughly with my health care agent and believe that he or she understands my philosophy regarding the health care decisions I would make if I were able. I desire that my wishes be carried out through the authority given to my health care agent under this document. If I am unable, due to my incapacity, to make a health care decision, my health care agent is instructed to make the health care decision for me, but my health care agent should try to discuss with me any specific proposed health care if I am able to communicate in any manner, including by blinking my eyes. If this communication cannot be made, my health care agent shall base his or her decision on any health care choices that I have expressed prior to the time of the decision. If I have not expressed a health care choice about the health care in question and communication cannot be made, my health care agent shall base his or her health care decision on what he or she believes to be in my best interest. LIMITATIONS ON MENTAL HEALTH TREATMENT My health care agent may not admit or commit me on an inpatient basis to an institution for mental diseases, an intermediate care facility for the persons with mental retardation, a state treatment facility or a treatment facility. My health care agent may not consent to experimental mental health research or psychosurgery, electroconvulsive treatment or drastic mental health treatment procedures for me. ADMISSION TO NURSING HOMES OR COMMUNITY-BASED RESIDENTIAL FACILITIES My health care agent may admit me to a nursing home or community-based residential facility for short-term stays for recuperative care or respite care. If I have checked Yes to the following, my health care agent may admit me for a purpose other than recuperative care or respite care, but if I have checked No to the following, my health care agent may not so admit me: 1. A nursing home - - Yes No 2. A community-based residential facility - - Yes No If I have not checked either Yes or No immediately above, my health care agent may admit me only for short-term stays for recuperative care or respite care.
F-00085 (Rev. 01/09) Page 4 of 6 PROVISION OF FEEDING TUBE If I have checked Yes to the following, my health care agent may have a feeding tube withheld or withdrawn from me, unless my physician has advised that, in his or her professional judgment, this will cause me pain or will reduce my comfort. If I have checked No to the following, my health care agent may not have a feeding tube withheld or withdrawn from me. My health care agent may not have orally ingested nutrition or hydration withheld or withdrawn from me unless provision of the nutrition or hydration is medically contraindicated. Withhold or withdraw a feeding tube - - Yes No If I have not checked either Yes or No immediately above, my health care agent may not have a feeding tube withdrawn from me. HEALTH CARE DECISIONS FOR PREGNANT WOMEN If I have checked Yes to the following, my health care agent may make health care decisions for me even if my agent knows I am pregnant. If I have checked No to the following, my health care agent may not make health care decisions for me if my health care agent knows I am pregnant. Health care decision if I am pregnant - - Yes No If I have not checked either Yes or No immediately above, my health care agent may not make health care decisions for me if my health care agent knows I am pregnant. STATEMENT OF DESIRES, SPECIAL PROVISIONS OR LIMITATIONS In exercising authority under this document, my health care agent shall act consistently with my following stated desires, if any, and is subject to any special provisions or limitations that I specify. The following are any specific desires, provisions or limitations that I wish to state (add more items if needed): 1. 2. 3. INSPECTION AND DISCLOSURE OF INFORMATION RELATING TO MY PHYSICAL OR MENTAL HEALTH Subject to any limitations in this document, my health care agent has the authority to do all of the following: (a) Request, review and receive any information, oral or written, regarding my physical or mental health, including medical and hospital records. (b) Execute on my behalf any documents that may be required in order to obtain this information. (c) Consent to the disclosure of this information.
F-00085 (Rev. 01/09) Page 5 of 6 (The principal and the witnesses all must sign the document at the same time.) SIGNATURE OF PRINCIPAL (Person creating the Power of Attorney for Health Care) Signature (The signing of this document by the principal revokes all previous powers of attorney for health care documents.) STATEMENT OF WITNESSES I know the principal personally and I believe him or her to be of sound mind and at least 18 years of age. I believe that his or her execution of this power of attorney for health care is voluntary. I am at least 18 years of age, am not related to the principal by blood, marriage or adoption and am not directly financially responsible for the principal's health care. I am not a health care provider who is serving the principal at this time, an employe of the health care provider, other than a chaplain or a social worker, or an employe, other than a chaplain or a social worker, of an inpatient health care facility in which the declarant is a patient. I am not the principal's health care agent. To the best of my knowledge, I am not entitled to and do not have a claim on the principal's estate. Date Witness Number 1 (Print) Name Date Address Signature Witness Number 2 (Print) Name Date Address Signature STATEMENT OF HEALTH CARE AGENT AND ALTERNATE HEALTH CARE AGENT I understand that (name of principal) has designated me to be his or her health care agent or alternate health care agent if he or she is ever found to have incapacity and unable to make health care decisions himself or herself. (name of principal) has discussed his or her desires regarding health care decisions with me. Agent's Signature Address Alternate's Signature Address
F-00085 (Rev. 01/09) Page 6 of 6 Failure to execute a power of attorney for health care document under chapter 155 of the Wisconsin Statutes creates no presumption about the intent of any individual with regard to his or her health care decisions. This power of attorney for health care is executed as provided in chapter 155 of the Wisconsin Statutes. ANATOMICAL GIFTS (optional) Upon my death: I wish to donate only the following organs or parts: I wish to donate any needed organ or part. I wish to donate my body for anatomical study if needed. (specify the organs or parts). I refuse to make an anatomical gift. (If this revokes a prior commitment that I have made to make an anatomical gift to a designated donee, I will attempt to notify the donee to which or to whom I agreed to donate.) Failing to check any of the lines immediately above creates no presumption about my desire to make or refuse to make an anatomical gift. Signature Date